Referring to: Nayak SS et al. Clinical outcomes of continuing vs discontinuing oral anticoagulation after atrial fibrillation ablation: an updated systematic review and meta-analysis of observational studies and randomized controlled trials.  Atrial fibrillation (AF) is one of the most commonly encountered heart conditions, and its prevalence is increasing as the population ages. Beyond its symptomatic burden, AF is associated with serious complications, of which thromboembolism is probably the most significant one. Generally, antithrombotic therapy decisions require careful assessment of thrombotic versus bleeding risks. In AF, these risks often arise from overlapping factors, including age, hypertension, prior stroke, vascular disease, and renal impairment, which contribute to both CHA₂DS₂-VA and HAS-BLED scores. According to the latest guidelines, anticoagulation should be considered in patients with AF and a CHA2DS2-VA score of 1 (class IIa) and is recommended in patients with ≥2 scores (class I).

Background: Coronary bifurcation lesions pose substantial challenges in percutaneous coronary intervention (PCI). This study aimed to assess the clinical and angiographic characteristics of patients undergoing PCI for bifurcation lesions in a South Asian population and to evaluate short-term outcomes.
Methods: This prospective observational study was performed from June 2022 through September 2023 at a tertiary cardiac care center in individuals undergoing PCI for coronary bifurcation lesions.
Results: A total of 259 participants were enrolled, with a mean (SD) age of 57.4 (10.9) years; 78.8% were male.The Medina classification indicated that the most common bifurcation lesion was left main–left anterior descending (LM–LAD) (43.2%). A total of 206 participants had LM bifurcation lesions, whereas 53 had non-LM lesions, with the LAD being the most frequently involved culprit vessel (94.2%). Ostial lesions were present in 68.3% of cases, and calcification was significantly more common in LM lesions (14.6%) than in non-LM lesions (1.9%; P=.01). Provisional stenting was the most common technique (62.6%), with double kiss crush used more frequently in LM bifurcation lesions (20.4% vs 3.8%; P < .001). Major adverse cardiovascular events (MACE) occurred in 38 participants (14.7%); they included 18 cardiac deaths (6.9%) and 13 cases of target vessel failure (TVF) (5.0%). No significant differences in MACE (P=.23) or death (P=.10) were observed between bifurcation lesion types or stenting strategies. Intravascular ultrasonography (IVUS) guidance was utlized in 70.3% of participants and was potentially associated with improved outcomes. Kaplan–Meier analysis revealed that severe left ventricular dysfunction was associated with a nearly 3-fold greater risk of death (hazard ratio [HR], 2.96; 95% CI, 0.98 to 8.96) and was the only independent predictor of all-cause mortality (HR, 3.23; 95% CI, 1.14 to 9.14; P=.027).
Conclusion: Procedural complexity and lesion-related factors were not significantly associated with short-term mortality. These findings emphasize the importance of addressing myocardial dysfunction in risk stratification and management to improve outcomes in this high-risk population.

Background: Patients with right ventricular (RV) pacing from permanent cardiac pacemakers have electrocardiographic (ECG) patterns similar to those with left bundle branch block (LBBB). Although ECG criteria for LBBB in patients with reduced left ventricular ejection fraction (LVEF) are well established, these criteria have not been clarified for patients with RV pacing.
Methods: In this retrospective observational study, between January 2016 and August 2025, 193 patients were diagnosed with LBBB, of whom 118 were included. During the same period, 475 patients with permanent cardiac pacemakers were identified, of whom 178 were eligible for the study.
Results: In the LBBB group (male/female, 55/63; mean [SD] age, 67 [12] years), 57% of patients had LV systolic dysfunction (LVEF <50%), whereas in the pacemaker group (male/female, 93/85; mean [SD] age, 72 [11] years), only 26% had an LVEF less than 50%. Mean QRS duration was longer in patients with reduced LVEF than in those with normal LV systolic function (155 [13] vs 147 [12] milliseconds, respectively; P=.034).
Conclusion: Although the ECG pattern associated with RV pacing from a permanent cardiac pacemaker resembles that of LBBB, its association with LV dysfunction differs. In patients with LBBB, longer QRS duration and the presence of q waves in leads I, aVL, V5, and V6 were associated with reduced LVEF, whereas in patients with RV pacing, a broad, notched, or slurred R wave in leads I, aVL, V5, and V6 was associated with reduced LVEF.

Background: Radiofrequency (RF) catheter ablation is the standard treatment for symptomatic patients with Wolff-Parkinson-White (WPW) syndrome. Successful RF ablation of an accessory pathway (AP) depends on accurate localization of its site.
Methods: This retrospective, observational, cross-sectional study included all consecutive patients who underwent successful RF ablation of a single manifest posteroseptal AP at the Cardiac Electrophysiology Laboratory of the Cardiovascular Department, Cairo University Hospitals. Twelve-lead electrocardiograms were collected and analyzed to identify electrocardiographic criteria that differentiate epicardial from endocardial posteroseptal APs to guide mapping and ablation strategies.
Results: Seventy-three patients with a posteroseptal AP were included: 47 were ablated from the right posteroseptal endocardium; 6 from the left posteroseptal endocardium; and 20 were ablated epicardially (from the coronary sinus or its branches). Epicardial posteroseptal APs were predicted by a negative delta wave in lead II, a positive delta wave in lead aVR, a positive delta wave in lead V1, and/or QRS complex notching in lead II. Endocardial posteroseptal APs were predicted by a negative delta wave in lead V1 and/or an R/S ratio less than 1 in lead V1. Double QRS transition was not useful for differentiation unless combined with a Q wave or predominantly negative QRS complex in lead V1.
Conclusion: Epicardial and endocardial posteroseptal APs can be differentiated based on delta wave polarity in leads II, aVR, and V1; R/S ratio in lead V1; and QRS complex notching in lead II.

Background: Anthracycline-based chemotherapy is associated with cancer therapy–related cardiac dysfunction, primarily manifested by a decline in left ventricular ejection fraction (LVEF). Sarcopenia, characterized by reduced skeletal muscle mass and strength, shares mechanistic pathways with anthracycline cardiotoxicity, including mitochondrial dysfunction, oxidative stress, and systemic inflammation. We aimed to investigate the association between postchemotherapy sarcopenia and changes in cardiac function in a heterogeneous cohort of patients with cancer.
Methods: In this single-center prospective observational study, 163 adult patients scheduled to receive anthracycline-containing chemotherapy were enrolled. Transthoracic echocardiography was performed before treatment and 3 months after completion, with assessment of LVEF using the biplane Simpson method and global longitudinal strain. Sarcopenia was assessed postchemotherapy using computed tomography–derived skeletal muscle index at the L3 level combined with handgrip strength. Cardiotoxicity was defined as a reduction in LVEF of 10% or more to below normal and/or new diastolic dysfunction. Multivariable logistic regression was used to evaluate independent associations.
Results: Sarcopenia was identified in 46% of patients following chemotherapy. Significant differences in echocardiographic outcomes were observed between sarcopenic and nonsarcopenic groups (P<.05). Sarcopenia was strongly associated with cardiotoxicity, with logistic regression demonstrating robust predictive performance (Nagelkerke R²=0.485; P<.001). Patients with low muscle mass and strength exhibited markedly higher odds of cardiac dysfunction.
Conclusion: Postchemotherapy sarcopenia is independently associated with anthracycline-induced cardiac dysfunction. Integrating CT-based muscle assessment and functional testing into cardio-oncology risk stratification may enhance early identification of vulnerable patients and guide cardioprotective strategies.

Background: Atrial fibrillation (AF) is a common cardiac arrhythmia associated with an increased risk of stroke, heart failure, and other adverse clinical outcomes. Self-care and treatment adherence are important components of preventing complications and improving long-term outcomes. This study aimed to assess AF-related knowledge, pharmacologic and nonpharmacologic treatment adherence, self-care behaviors, and health care utilization among patients attending the Atrial Fibrillation Clinic at Tehran Heart Center.
Methods: This cross-sectional study was conducted between January and February 2024 among 144 patients randomly selected from the Atrial Fibrillation Clinic at Tehran Heart Center. Data were collected via telephone interviews using the Persian version of the Jessa Atrial Fibrillation Knowledge Questionnaire, a researcher-developed Atrial Fibrillation Self-Care Adherence Behavior Scale (AF-SCABS), and questions assessing health care utilization during the previous 6 months. Data were analyzed using descriptive statistics, t tests, analysis of variance, χ2 tests, and logistic regression analyses.
Results: Participants had a mean age of 62.36 (11.40) years, and 56.2% were male. Fifty percent demonstrated moderate knowledge of AF, whereas 41.0% had poor knowledge. Only 20.8% demonstrated good pharmacologic treatment adherence. Poor adherence to nonpharmacologic treatment was observed in 45.8% of participants, and 52.1% reported poor overall self-care behaviors. During the previous 6 months, 42.4% had visited the emergency department, 21.6% had been hospitalized, and 13.9% reported hospital stays of 2 or more days. In multivariable analyses, knowledge, treatment adherence, and self-care were not independently associated with emergency department visits or hospital admissions.
Conclusion: Patients with AF demonstrated limited disease-related knowledge, suboptimal treatment adherence, and poor self-care behaviors, highlighting the need for context-specific educational and behavioral interventions to support effective self-management.

Background: Dasatinib is a tyrosine kinase inhibitor commonly used as first-line treatment for chronic myeloid leukemia (CML). Although pulmonary complications are uncommon, dasatinib has been associated with serious adverse effects, including pulmonary arterial hypertension (PAH). Dasatinib-related PAH is currently categorized within group 1 PAH associated with drugs and toxins. We present a case of persistent PAH that developed during long-term dasatinib therapy and was managed with sequential bosentan and riociguat.
Case Presentation: A 52-year-old woman with chronic-phase CML developed progressive exertional dyspnea and fatigue after 5 years of dasatinib treatment. She also had severe PAH and bilateral pleural effusions. Transthoracic echocardiography revealed right-sided cardiac enlargement, with a tricuspid regurgitation jet velocity of 3.9 m/s. Right heart catheterization confirmed precapillary pulmonary hypertension consistent with group 1 PAH. Thoracic computed tomography demonstrated bilateral pleural effusions. Dasatinib-related PAH was considered the most likely diagnosis; dasatinib was discontinued and replaced with nilotinib. Prednisolone was administered for approximately 4 months for the pleural effusion.
According to the 2022 ESC/ERS pulmonary hypertension guidelines, the patient was classified as being at intermediate risk before initiation of PAH-targeted combination therapy. Bosentan was initially prescribed. Because the clinical and hemodynamic response remained inadequate, riociguat was subsequently added. Following the introduction of riociguat, the patient’s symptoms improved substantially, and the clinical risk status decreased to the low-risk category. Nevertheless, right heart catheterization performed after 1 year of combination treatment demonstrated persistent pulmonary hypertension despite the marked clinical improvement.
Conclusion: Dasatinib is an important therapeutic option for patients with CML but may cause persistent pulmonary vascular abnormalities. Prompt recognition of PAH, withdrawal of dasatinib, and appropriately individualized PAH-directed treatment may lead to substantial clinical and hemodynamic improvement. This case also highlights the possibility that pulmonary vascular abnormalities may persist despite symptomatic recovery.

Background: Myocarditis in women of reproductive age poses unique challenges for pregnancy planning, particularly when assisted reproductive technology (ART) is considered. Current guidelines lack specific recommendations for pregnancy after myocarditis, especially in the presence of residual ventricular dysfunction or myocardial fibrosis.
Case Presentation: We describe a 43-year-old woman who developed acute myocarditis shortly after controlled ovarian stimulation for in vitro fertilization. Cardiac magnetic resonance imaging confirmed myocardial inflammation with a markedly reduced left ventricular ejection fraction. She was treated with guideline-directed medical therapy and showed progressive improvement on follow-up imaging, including recovery of contractile reserve on dobutamine stress echocardiography. After a comprehensive prepregnancy evaluation and multidisciplinary consultation, she proceeded with frozen embryo transfer, with close surveillance during gestation.
Discussion: This case highlights the importance of individualized, multimodal risk assessment before pregnancy in women with prior myocarditis. Cardiac magnetic resonance imaging and stress echocardiography can provide valuable prognostic information beyond conventional echocardiographic measures. In addition, we review the potential temporal association between ART and myocarditis, outline proposed mechanisms, and summarize current recommendations for reproductive planning in this population.
Conclusion: With careful risk stratification and coordinated care, pregnancy may be considered in selected women with a history of myocarditis.

Background: Gallbladder and biliary tract diseases may manifest as cardiac symptoms, ischemic electrocardiographic changes, and arrhythmias. Albeit rare, cases of bradyarrhythmia caused by the cardiobiliary reflex have been reported in the context of acute cholecystitis. The case discussed herein emphasizes the cardiobiliary reflex as a possible cause of bradyarrhythmia in patients with gallbladder and biliary tract diseases.

Background: Takotsubo syndrome (TTS) may mimic acute myocardial infarction and occasionally occurs in patients with hypertrophic cardiomyopathy (HCM), creating important diagnostic and therapeutic challenges.
Case Summary: A 76-year-old man with diabetes mellitus, hypertension, smoking history, HCM, and prior coronary angioplasty presented with chest pain and anterior ST-segment elevation. Transthoracic echocardiography demonstrated severe left ventricular systolic dysfunction with apical hypokinesia, whereas coronary angiography showed no obstructive culprit lesion, consistent with myocardial infarction with non-obstructive coronary arteries (MINOCA). During hospitalization, the patient developed worsening dyspnea, tachycardia, and hypotension. Repeat echocardiography demonstrated persistent severe left ventricular dysfunction and hypertrophy of the mid-anteroseptal wall suggestive of dynamic obstructive physiology in the setting of HCM. Because β-blocker therapy was considered necessary for hemodynamic stabilization in a patient with previously documented high-grade atrioventricular block and bifascicular block, a temporary transvenous pacemaker was implanted before initiation of β-blockade. Cardiac magnetic resonance imaging demonstrated extensive apical edema with limited late gadolinium enhancement, supporting TTS rather than ischemic myocardial infarction or myocarditis superimposed on underlying HCM. Owing to preexisting conduction disease, the patient ultimately underwent implantable cardioverter-defibrillator placement. One month later, complete recovery of ventricular systolic function was observed.
Discussion: This case highlights the complex interaction between TTS and HCM and emphasizes the importance of distinguishing preexisting conduction disease from arrhythmias directly attributable to TTS.